Research Paper

Mackenzie Digmann

Preventive Dentistry
 Acquired pellicle is a thin, acellular, non-bacterial film composed of proteins,

carbohydrates, and lipids; it is uniquely positioned on exposed tooth surfaces as an interface

between the tooth and the oral environment. (Wilkins, 2017, p. 256). Since it is non-bacterial, it

does not directly cause disease; it does provide an attachment site for other disease causing

bacteria such as strep mutans found in plaque. Plaque is a dense, organized bacterial system that

is embedded in an intermicrobial matrix held together by glucan. Plaque formation occurs in a

predictable series of interactions, starting with the attachment of bacterial cells to the pellicle on

the tooth surface. During this stage, the bacterial cells are not yet committed to this process

which means it can be reversed by disrupting the adhesion from means of oral hygiene activities

such as brushing and flossing. If the microorganisms are not disrupted, they will attach

themselves more firmly to the pellicle. They will multiply in layers, growing up and outward to

produce extracellular polymeric substance (EPS) to attach in an irreversible way. EPS is made up

of polysaccharides, glucans, and fructans produced by the bacteria within the community and

dietary sucrose. This matrix protects the bacterial community by anchoring them together which

makes its adherence to the tooth and other surrounding structures sounder, making it a challenge

to remove or disrupt. The bacterial matrix continues to development and enhances a cell to cell

communication process known as quorum sensing. Quorum sensing involves the detection and

response to extracellular signaling molecules called autoinducers. They accumulate in the

environment as the bacterial community increases and the bacteria monitor this information to

track changes in their environment to be able to survive longer. (Rutherford & Bassler, 2012).

The final stage is the maturation of the colonies to the point where they release planktonic cells

to spread and colonize other areas in the oral cavity. (Wilkins, 2017, p. 258-259).
 Dental caries is an infectious, transmissible disease of the calcified structures such as the

enamel, dentin and cementum characterized by the demineralization of their components

(Wilkins, 2017, p. 265). Streptococcus mutans, streptococcus sobrinus and lactobacilli acid

forming bacteria are found in plaque that contribute to the caries process. Specific bacteria in the

plaque matrix metabolize the fermentable carbohydrates that are ingested by the patient and turns

them into acid. The acid will demineralize the calcified structures and lead to a cavity formation.

The acid passes freely into the small channels of the matrix to come into contact with the tooth

surface and then dissolve the enamel crystals and turn it into calcium and phosphate ions; this is

observed as a white area (Wilkins, 2017, p. 436). Demineralization is the process in which the

minerals of the tooth structure are dissolved into solution by the organic acids produced from the

fermentable carbohydrate by the bacteria. Remineralization is the process of moving minerals

back into the subsurface of the enamel and the saliva provides protection and promotes

remineralization. These two processes are naturally occurring within the oral cavity as the fluids

are constantly striving to maintain equilibrium. When the oral cavity is repeatedly bathed with

acids over the course of a day, the tooth demineralization can outpace the remineralization

process and the result is a carious lesion. Frequent ingestion of fermentable carbohydrates such

as bread, crackers, cereals, cookies, and soft drinks have a major influence on the amount of acid

produced and aid in the tooth destruction. The acid also promotes the growth of streptococcus

mutans and lactobacilli in plaque. It is important to be aware of how frequently acid producing

foods are ingested and to give patients helpful tips if that is a problem in their diet. Chewing

sugar-free gum after meals or snacks can help rid of the harmful acid from the oral cavity;

chewing sugar-free gum containing xylitol, an artificial sweetener, can have an added benefit of
decay-preventive qualities. Research has shown that xylitol inhibits the growth of streptococcus

mutans (Food for and against your teeth (2018)).

Calculus is mineralized plaque composed of crystals of calcium phosphate mineral salts

of previously living microorganisms (Wilkins, 2017, p. 350). If plaque is left undisturbed for 24-

72 hours, mineralization takes place to result in calculus. The new living bacteria that makes up

plaque adheres to the hard calculus which provides it with more surface area and closer contact

to the gingiva. Supragingival calculus is on the clinical crowns of the teeth as well on implants

and complete/partial dentures. This type is usually found near openings of the ducts of salivary

glands which are the lingual surfaces of mandibular anterior teeth (submandibular salivary gland)

and on the facial surfaces of maxillary first and second molars (parotid salivary gland). It is

moderately hard where newer deposits are less dense and hard and it takes on a light color

ranging from white to a creamy yellow and gray. Subgingival calculus is on the surface below

the gingiva margin. Heaviest deposits are related to areas that are difficult for the patient to clean

during homecare and the bacteria colonies were left undisturbed. It is harder than supragingival

calculus and the newest deposits near the bottom of the pocket are less dense and hard; it takes

on a dark color ranging from dark green to black.

Gingivitis is inflammation of the gingival tissues that is usually painless and often

unrecognized by the patient in the early stages. It typically fully develops two to three weeks

when plaque is left undisturbed on the tooth surface (Wilkins, 2017, p. 261). Within the first few

days of the gingiva being in contact with the plaque, it causes an acute inflammatory response

and white blood cells attach to the dilated vessel walls and migrate into the connective tissues;

Plasma leaks into those surrounding tissues and causes swelling. Four to seven days after plaque

has been in contact with gingiva, the tissue appears slightly red and swollen. The collagen fibers
are destroyed and replaced by blood plasma and the junctional epithelium begins to elongate.

Although the gums are irritated and look abnormal, the teeth are still secured firmly in their

sockets and no irreversible bone or tissue damage has occurred at this point (Gingivitis and

Periodontal Disease (Gum Disease) (2017). Fifteen to twenty-one days of left untreated, plasma

cells predominate which is associated with an infection response as pus is visible. The junctional

epithelium, epithelial component that is directly attached to the tooth surface and acts as a

protector against diseases, thickens and extends more towards the apex and the gingiva appears

redder due to the rapid formation of capillaries. (Yajima-Himuro, S. et al., 2014). When probe

measurements are taken and bleeding occurs, this is a major clinical indicator or gingivitis

(Clark, 2018).

When gingivitis is left untreated, it can result in periodontitis. This is an infection that

damages the soft tissues and bone structures. The inner layer of the gingiva and the bone

structure pull away from the teeth and form pockets which can cause tenderness, recession,

spaces to form between teeth and loose teeth that can ultimately result in the loss of them. Once

the bone or tooth structure is damaged, it is irreversible; It is important for these patients to

commit to a strict homecare routine to prevent further damage. With periodontitis, the oral cavity

has an abundant amount of gram-positive bacteria that is not only harmful to the mouth, but

some research has shown that the bacteria can enter the bloodstream through the gum tissue

which will travel throughout the body and have the possibility to affect the heart and lungs.

Patients who have this disease are recommended to get deep scaling and root planing from a

periodontist, if the disease is advanced, or from a dental hygienist for less advanced cases.

Antibiotics can be prescribed to the patient to control the bacteria infection; topical antibiotics
include mouth rinses or insertion of gels to get interproximal and oral antibiotics may be

necessary if the bacteria is out of control and need to be eliminated (Periodontitis (2018)).

Diseases in the mouth are devastating but they are preventable, for the most part.

Exceptions would be side effect from medications or genetics, but that is a different topic of

discussion. Patients who do proper oral hygiene activities every day, use auxiliary aids as

needed, and receive regular professional cleanings greatly reduce their risk of developing caries

and diseases. As a dental health professional, it is important to understand that patients need to

be psychologically ready and motivated to make changes for the information to stick with them.

When the patient is ready to learn about strengthening their oral hygiene skills, it is typically

recommended to teach the Bass tooth brushing technique. This includes angling the soft

toothbrush bristles 45 degrees towards the gum line and making soft, circular motions for ten

seconds then moving to the adjacent tooth until all tooth surfaces are cleaned, ending with

scrubbing the occlusal surfaces and tongue. With young children, their dexterity usually is not

fully developed so the Bass method may be tricky for them. Teaching them the Roll method is

much easier to perform where they sweep the bristles from the gum line towards the occlusal or

incisal surface of the tooth. It is also important to teach the importance of proper interdental

cleaning which is best achieved by flossing. String floss is best to use by sawing it gently

through the contact point and making a “C” shape around each tooth and sliding up and down the

sides of the tooth. Brushing and flossing at least twice a day will disrupt the bacteria in the oral

cavity on the tooth surfaces as well as in the gum line which will control plaque to prevent caries

any diseases to develop within the mouth. If patients need extra help with these techniques, there

are an abundant choices for auxiliary aids such as a water pick, interdental brush, and superfloss.

The dental professional should be cautious to not overload the patient with multiple options and
should introduce one aid at a time and see if it is a good fit for the patient. Educating the patient

on nutrition is also important, especially if they have existing concerns within the oral cavity.

The general population might think sweets, sodas and candies is what causes cavities when in

reality, it is so much more than that. Carbohydrates such as cereals, crackers, breads, fruits and

even vegetables go through a chemical reaction in the mouth to produce sugars, and the bacteria

thrive off that. Teaching them to not frequently snack throughout the day and if they do, teach

ways to help neutralize the mouth pH by drinking a glass of milk or water. Proper nutrition will

also help control the bacteria that makes up plaque which prevents any further damage to the oral

cavity (Clark, 2018).

 References

Clark, S. (2018) Preventive Dentistry Class Notes, Kirkwood Community College.

Food for and against your teeth (2018). Delta Dental.

Gingivitis and Periodontal Disease (Gum Disease) (2017). Reviewed by Friedman, M. DDS.

WebMD Medical Reference.

Periodontitis (2018). Mayo Clinic.

Rutherford S. T., & Bassler B. L. (2012). Bacterial Quorum Sensing: Its Role in Virulence and

Possibilities for Its Control. Cold Spring Harbor Perspectives in Medicine.

Wilkins, E. M. (2017) Book. Philadelphia, PA: Wolters Kluwer

Yajima-Himuro, S., Oshima, M., Yamamota, G., Ogawa, M., Furuya, M., Tanaka, J., Nishii,

K.,… Yamamoto, M. (2014). The junctional epithelium originates from the odontogenic

epithelium of an erupted tooth. US National Library of Medicine National Institutes of

Health.